Hospice Care Informal Questionnaire

We have also prepared the following brief questionnaire that can help you determine
if hospice care, care at assisted living facilities is right for you or your loved
one.

You or your loved one may be eligible for hospice care if you check 4 or more statements.
However, your primary physician and our Medical Director will make the final decision
regarding eligibility.

Please review the following statements as they apply to you or your loved one to
see if hospice care may be appropriate.

I have started feeling more tired and weak

I experience shortness of breath, even when resting

I spend most of the day in bed or in a chair

I have noticed an increased weight loss in the past six months

I make frequent phone calls to my physician

I take medications to lessen physical pain

I have fallen several times in the past six months

I have made frequent trips to the emergency room in the past six months

I need help from others with important daily activities (bathing, dressing, eating,
cooking, walking, getting out of bed)

My doctor has told me my life expectancy is limited

If you have checked 4 or more items on the questionnaire, you may want to begin
your research into hospice care by seeking the opinion and advice of your (or the
affected individual’s) primary physician. If you do not have a primary physician,
we will be happy to refer you to our Medical Director, who is a Doctor of Internal
Medicine.